Massage Permission, Consent & Release Form For Minor Children & Youth

Massage Permission, Consent & Release Form For Minor Children & Youth
Name of Minor Child / Youth *

First NameLast Name
Name of Parent or Guardian*

First NameLast Name
If you will not be in attendance during the minor child / youth's massage session please provide the name of the responsible adult that will be in attendance

First NameLast Name
Birthdate of Minor Child / Youth*

MonthDayYear
Date
My minor child / youth has the following health condition(s) that may affect their ability to receive a massage:
By signing below, I agree to the following;

I am the parent or guardian of the above named minor child / youth. I agree to be in attendance during my child / youth massage session, or have assigned another resposible adult to be there in my absence.

I acknowledge that massage should not be performed under certain health conditions and accept that to the best of my knowledge my child is physically and mentally healthy enough to receive a massage session. The massage practitioner has been informed of any and all health conditions that may effect the minor child / youth's ability to safely receive a massage.

Every effort will be made by the massage practitioner to do no harm. However, I agree that my child is physically and mentally able to inform the massage practitoner if they feel any pain or discomfort during the massage session, so adjustments can be made to ensure their comfort and safety.

I, hereby consent and give permission for the massage service that my minor child /youth will receive and also, will take full responsibility for their behavior and consent to release and indemnify Jennifer Reiter and Refresh Bodywork from any and all liability claims, damages, causes of action whatsoever, for loss, damage, or injury to person or property that may result from the minor child / youth participating in and receiving this massage.
Date of Massage Event or Spa Party *

MonthDayYear
Date
Today's Date (if different from date of Massage Event)

MonthDayYear
Date
Signature of Parent or Guardian*

Clear
Should be Empty: